Bankruptcy Petition Form

BANKRUPTCY PETITION FORM

Debtor Name:    SSN or EIN:    Filing Date:

Principal Place of Business or Residence:

RECITALS

WHEREAS, Debtor is unable to pay debts as they mature and seeks the relief afforded under the Bankruptcy Code; and

WHEREAS, Debtor intends to file all required schedules, statements of financial affairs and related pleadings necessary to commence a case under Title 11 of the United States Code; and

WHEREAS, relief is sought for an orderly administration of Debtor's estate, protection from creditor collection actions, and an opportunity for reorganization or discharge as provided by law.

NOW, THEREFORE, in consideration of the representations and statements set forth below, Debtor petitions this Court for relief under the Bankruptcy Code and asserts the following:

1. JURISDICTION AND VENUE

Debtor affirms that this Court has jurisdiction over the subject matter of this petition under 28 U.S.C. § 1334 and that venue is proper in this district because Debtor's domicile, residence, principal place of business, or principal assets are located in this district. Debtor consents to the entry of orders by the bankruptcy court consistent with applicable law.

2. PETITION FOR RELIEF

Debtor hereby petitions for relief under the Bankruptcy Code. Debtor selects the chapter of relief by checking the applicable box below:

Chapter 7 — Liquidation    Chapter 11 — Reorganization    Chapter 13 — Individual Repayment Plan

3. SCHEDULES AND STATEMENTS

Debtor understands and affirms that complete and accurate Schedules A through J, a Statement of Financial Affairs, a list of creditors in the required format, and other required filings will be prepared and filed with this petition.

4. LIST OF CREDITORS

Debtor will file a creditor matrix in the form required by the court and will provide notice to all creditors as required by statute and court rules. Debtor certifies that to the best of Debtor's knowledge the creditor list is complete and accurate.

5. ASSETS, EXEMPTIONS AND ESTIMATED AMOUNTS

Estimated aggregate nonexempt assets: $    Estimated aggregate liabilities: $    Estimated monthly income: $

6. AUTOMATIC STAY AND RELIEF REQUESTED

Upon filing, Debtor requests entry of an order imposing the automatic stay under 11 U.S.C. § 362 staying all collection actions, and such other relief as may be necessary to preserve estate assets, protect estate property, and permit the effective administration of the case.

7. ATTORNEY INFORMATION

8. VERIFICATION AND CERTIFICATION

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct to the best of my knowledge, information and belief. I acknowledge that I am familiar with the penalties for false statements and that I have read and understand my continuing duty to amend schedules and statements as required by law.

9. NOTICES

All notices, requests, and demands in connection with this petition shall be in writing and delivered to the addresses provided above for Debtor and Attorney. Service by mail to the addresses set forth herein shall be effective upon deposit with the postal service.

10. AMENDMENTS, WAIVER, COUNTERPARTS

This petition may be amended by written amendment filed with the Court. No waiver of any provision of this petition shall be effective unless in writing signed by the waiving party. This petition may be executed in counterparts, each of which shall be deemed an original and all of which together constitute one instrument.

11. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

This petition shall be governed by and construed in accordance with the United States Bankruptcy Code and applicable federal and local bankruptcy rules. This document, together with any schedules and statements filed herewith, constitutes the entire petition and agreement between the parties with respect to the subject matter hereof. If any provision of this petition is held invalid or unenforceable, the remaining provisions will continue in full force and effect.

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